updated December 8th 2022

The UK government has recently issued warnings about Group A Streptococcus (GAS) and an unexpected number of deaths of children from complications of GAS infection in the last 3 months of 2022.

Background

So far this season, there have been 15 recorded deaths within 7 days of an IGAS (Invasive Group A Streptococcus) diagnosis in children under 10 in England. During the last high season for Group A Strep infection (2017 to 2018), there were 4 deaths in children under 10 in the equivalent period.

But what is Group A Streptococcus, and what is the reason for the increase in fatal cases?

Symptoms of Group A Streptococcus Infection

Group A Streptococcus is a germ (bacterium) that causes a number of different conditions, including

• Scarlet fever,
• Impetigo and
• ‘Strep throat’ (otherwise known as bacterial tonsillitis).

Scarlet fever commonly affects kids aged 2-8 years and is seen more often during winter. Studies indicate that the risk of contracting GAS in England is usually highest between December and April, usually affecting between 3000-4000 people. 

It has the following symptoms (initial features):

• Sore throat,
• fever,
• muscle aches,
• headache,
• fatigue,
• vomiting and
• tummy pain.

These symptoms are shortly followed by a red, generalised rash that begins from the trunk and spreads outwards. It fades (blanches) with pressure. The rash may look darker on non-caucasian skin and is often described as being rough or having the texture of sandpaper. 

Other symptoms include:

• A furry, coated white tongue which peels and appears like a bright red spotty (beefy) tongue resembling a strawberry.
• The tonsils may be inflamed and swollen, with complaints of difficulty eating and drinking.
• Swollen (lymph) glands in the neck

Impetigo is a (highly contagious) skin infection very common in kids of school age, with crusty sores developing on the face (around the mouth and cheeks).

They may be of different sizes and less often affect other body parts, too. Most often, the affected person is generally well but will need antibiotics (cream or medicine) to treat the condition.

IGAS and other Gp A Strep Complications

Other severe illnesses can arise from some Group A Streptococcus strains and occur when the germ invades the blood and spreads to other organs. This is known as invasive Group A Streptococcus infection and includes

• Peritonsillar abscess (a complication of acute tonsillitis in which pus collects in the space around the tonsils).
• septicaemia (aka blood poisoning: a life-threatening reaction to an infection)
• Meningitis (an infection of the protective membranes that surround the brain and spinal cord, which quickly becomes life-threatening)
• Pneumonia (swelling /inflammation of the tissue in one or both lungs. It’s usually caused by a bacterial infection or a virus)
• osteomyelitis (a painful bone infection)
• Other severe and sometimes life-threatening IGAS infections.
  • IGAS results in two rare but extremely severe conditions: necrotizing fasciitis (infection of muscle and fat tissue) and streptococcal toxic shock syndrome (a rapidly progressing infection causing low blood pressure/shock and injury to organs such as the kidneys, liver and lungs). IGAS was responsible for the recent deaths of children in the UK.

In addition, diseases can arise following infection with GAS (post-streptococcal):

• Rheumatic fever
• Glomerulonephritis.

Challenges of Diagnosis & Treatment of Group A Streptococcus

Thus, the initial GAS infection appears quite similar to other conditions, such as the common cold (from a viral infection).

Usually, developing the typical rash may raise suspicions of the infection.

However, the rash may not be so easy to differentiate – a skin rash (viral exanthem) may accompany some viral infections. Still, these do not have the sandpaper texture of the scarlet fever rash.

They (viral exanthem) are benign skin changes often resulting from the immune system as the body fights the infection.

Recognising how several conditions share a similar appearance to GAS, UK health authorities have directed vigilance on suspecting GP A strep when children arrive with these common symptoms.

A throat swab is encouraged to detect this difference, followed by prompt antibiotic treatment.

The official advice in the face of the current outbreak is:

We are seeing a higher number of cases of Group A strep this year than usual. The bacteria usually causes a mild infection producing sore throats or scarlet fever that can be easily treated with antibiotics. In very rare circumstances, this bacteria can get into the bloodstream and cause serious illness – called invasive Group A strep (iGAS). This is still uncommon; however, it is important that parents are on the lookout for symptoms and see a doctor as quickly as possible so that their child can be treated and we can stop the infection becoming serious. Make sure you talk to a health professional if your child is showing signs of deteriorating after a bout of scarlet fever, a sore throat, or a respiratory infection.

Dr Colin Brown, Deputy Director, UKHSA

Is Infection with GAS Treatable?

Yes – treatment is usually with a course of Penicillin-based antibiotics (or an alternative if there is a known allergy to Penicillin). Antibiotics reduce the risk of disease spread.

• A 10-day course of Penicillin V,
• 10-day course of Amoxicillin or
• as an alternative to Penicillin, a 5-day course of Azithromycin

But some cases recover without treatment (kids who do not have antibiotics should be excluded from school for 2 weeks).

However, remember that not all sore throats, fevers or rashes require antibiotics.

Other measures for self-care include

• Rest,
• Adequate fluids,
• A regular diet and
• Using over-the-counter paracetamol or ibuprofen for symptom relief if there are no contraindications.
• Advise to clean and cover any skin breaks, including bites, cuts, grazes, or wounds.

Some Features of GAS

*Highly contagious infection

*Infects throat and skin – responsible for strep throat infection and impetigo

*3-26% of healthy people are asymptomatic carriers

*From the time of infection to the onset of illness (incubation period) is usually 2-3 days, but can be up to 6 days 

* Transmission is by breathing infected airborne droplets produced through coughing or sneezing) or by direct contact with contaminated surfaces – hand hygiene is important. (And so spread in nurseries through shared toys/cups, etc.)

*People can remain infected for 2-3 weeks if untreated.

*Children infected with GAS should be excluded from school until they’ve had 24 hours of antibiotics.

Who’s at Risk of getting IGAS/other Streptococcus Complications?

People who are at increased risk of invasive Group A Streptococcal infection (iGAS) and complications include those: (source NICE Clinical Knowledge Series)

• At extremes of the age range, such as very young and old people or postpartum women (soon after delivery).
• Who are immunocompromised or immunosuppressed.
• With comorbidities such as skin breakdown, diabetes mellitus, or underlying malignancy.
• With concurrent chickenpox or influenza.
• Who inject drugs or are alcohol dependent.

When to Seek Medical Advice

Any parent worried about their child in any way should seek medical advice.

In addition, see your GP if they are:

• Not eating or drinking
• Sleeping excessively
• Unable to control the temperature
• Failing to pass urine
• Unwell and under the age of three months

You should attend the ED or call 999 if they:

• Have breathing difficulty
• Find it difficult to stay awake
• Have a non-fading rash (glass test)
• Cold, clammy (sweaty) skin, pale or blue lips

We don’t know why there’s a rise in fatality from complicated GAS infections.

One thought under consideration is whether they result from lower-than-normal immunity levels caused by Covid measures. While we work on understanding this development, parents are encouraged to be vigilant and doctors to have a low threshold for starting antibiotics in kids with Group A Strep symptoms.

More Reading

• Antibiotics – How long should you have them?
• Managing Cough (& other respiratory problems) from Covid at Home
• My Blood Group is Different From That of ‘My Kids’.
• Why Antibiotic Resistance Matters To You
• Common Reasons You Snore and How to Treat Them

Editing by AskAwayHealth Team

Disclaimer

All AskAwayHealth articles are written by practising  Medical Practitioners on a wide range of healthcare conditions to provide evidence-based guidance and to help promote quality healthcare. 

The advice in our material is not meant to replace the management of your specific condition by a qualified healthcare practitioner.
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